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C19 61 Cs % w i ► 6 � Yr � <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> [:- - <br /> TYPE OF ACTION ❑ 1 . NEW PERMIT ❑ 5. CHANGE OF INFORMATION X7. PERMANENT FACILITY CLOSURE I Q 400 <br /> (Check one item only) El 3 , RENEWAL PERMIT El 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT l� l Gf <br /> I. FACILITY INFORMATION .FkDO;Z T A05g1g1P <br /> TOTAL NIJM3hFR OF USTs AT FACILITY 404. FACILITY ID # I 1 _ 1 _ I <br /> I owld (Agency Use Only) <br /> BUSINESS KAME (s memFACII.I'I',Y. /NAMEorDBA - Doin BBuusiine As) <br /> USINESS SITE ADDRESS 103. CITY 104. <br /> w � � i <br /> FACILITY TYPE ❑ I . MOTOR VEHICLE FUELING 112. UEL DISTRIBUTION 403 Is the facility located on Indi Reservation or 4os. <br /> 3 . FARM ❑ 4. PROCESSOR ❑ 6. OTHER Trust lands? ❑ Yes o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> MAILING ADDRESS 409 <br /> � <br /> , <br /> � � ems/ c� ,� �J � i / <br /> ODE 412. <br /> CITY 410 STATE 411 . ZIP C <br /> FYI <br /> 2 �4. <br /> IH. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 . PHONE 428-2 <br /> 2z72 ) ee -�5 <br /> 4283 <br /> MAILING ADDRESS <br /> CITY 428-4 STATE a2s-s ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME aOf <br /> 414. PHONE / 411. <br /> MAILING ADDRESS � ) 416. <br /> / ; 7 2 <br /> CITY � �� � a17. STAT - als. ZIP CO 419. <br /> r <br /> OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5 . COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br /> ❑ 7. FEDERAL AGENCY I, NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44- Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. <br /> VI, PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER El4. TANK OPERATOR <br /> cirl TANK OWNER ❑ 5. FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with le al requirements. <br /> PLIC T SIGNATURE t DATE N L7" aza. PHOS a2s. <br /> �,491221 <br /> L �5�? <br /> PLICANT NAME (print) �_ 426. APPLIC TITL ® 427 <br /> UPCF UST-A Rev. (12/2007) <br />